Services that currently have a temporary code or are considered experimental

Note: Denied or rejected claims with services in the scope of coverage are not considered noncovered services

Note: ADSM may be covered for the above noncovered services on a case-by-case basis as long as there is a valid authorization and or active duty waiver from their military hospital or clinic.

The beneficiary must agree in advance and in writing to receive and accept financial responsibility for noncovered services. The agreement must document the specific services, dates, estimated costs and other information. Network providers must use the TRICARE noncovered services waiver form to satisfy these requirements. A general agreement to pay, such as one signed by the beneficiary at the time of admission, is not sufficient to prove that a beneficiary was properly informed or agreed to pay.

If the beneficiary does not sign a TRICARE noncovered services waiver form, the provider is financially responsible for the cost of noncovered services he or she delivers.

Network providers should keep copies of the TRICARE noncovered services waiver form in their offices. Download the form now